Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Saturday, September 11, 2010

First the Residents, Then the Attendings

Residents have such long work hours! I fully support residents only having to work 56 hours a week:

Last week several groups, including Public Citizen and the American Medical Student Association, along with leading medical researchers, petitioned the Occupational Safety and Health Administration to step in and limit the number of hours that physicians-in-training can work. They contend that shorter hours will protect patients as well as the doctors' own health and safety.

Resident physicians should have work limits to reduce mistakes caused by fatigue, just as the federal government restricts the time spent working for employees in aviation, railroad, maritime and highway transportation jobs, according to the advocates.

The groups want OSHA to require that hospitals record and retain the work schedules of residents and fellows and that the agency conduct surprise inspections, establish confidential whistle-blower procedures and levy fines for violations.

Responsibility for regulating and enforcing work hours for resident physicians now falls to the Chicago-based Accreditation Council for Graduate Medical Education.

I say, go for it!

Then make sure attendings get the same treatment.

After all, we know medical issues only happen during the day. As you can plainly see, as we extrapolate these same workplace restrictions to attending physicians, nurses will risk being in violation of OSHA regulations if they call us after hours!

Perfect!

No, more late night interruptions of my sleep cycles. No more weekend call! Patient's won't suffer a bit! Even they'll get more sleep! See how good this will be for everyone? Especially when we add tens of millions of more people to the health care ranks in 2014 - everyone's going to LOVE the hours!

8 comments:

Hmm. I think a 56 hour workweek is a bit extreme, but I work in NY where the Bell Commission requires an 80 hour workweek, more or less.

Putting patient care aside for a second, it isn't safe for anyone to drive home after 27 hours of being awake. I know a ton of people who have been in very bad car accidents. And I know that you could always sleep more in the call room, but frankly speaking, the chance to see your loved ones for just a few minutes in the morning when you haven't seen them all week long is motivation enough to hightail it home.

I think 80 hours is a reasonable amount of time to be working - my dad did this amount for years, as a non-medical person. What creates the danger is the hours on end without sleep, adequate food and water intake. I'm a big believer in continuity of care, both for the patient as well as for the learning experience. But one way we can make safer shiftwork happen is by drastically kicking up our efforts at thorough patient handoffs.

Also, I find that I am less bitter about my work hours when I remember that the guy at Dunkin' Donuts had to get up just as early as me, and he has to spend the whole day resisting bowties. I just don't have that kind of strength of character =P

There are plenty of surgical, family medicine, IM, and OB/gyn residency programs in the US that have reduced or eliminated the q4 torture that is hurting both medical residents and patients. For residents, a 24 hour shift means more needlestick injuries, decreased concentration, as well as lower satisfaction with their program. For patients, a 24 hour shift means having a doctor who is more prone to commit errors care for you (which leads to more medical errors). All of this has been shown through clinical studies. hourswatch.org is a great resource.

No one is suggesting that no one work nights Dr Wes. We are suggesting an end to the 24 hour call that hurts residents, patients, and the families of both.

The point here is that having OHSA regulations cuts both ways. Why are we constantly insisting that doctors have no ability to maintain autonomy regarding their personal lives and, instead, leave it up to the regulators?

I understand about housestaff. It IS miserable to be up 24 hours with a patient. But guess what - sometimes that's the right thing to do. No one is suggesting housestaff be subjected to unreasonable hours on a regular basis. But more turnovers also create more handoff errors, surgical residents aren't getting enough cases to become credentialed in some centers so patients suffer if doctors don't have enough training either.

Bottom line - work hours cut both ways. And as residents work hours decline, we're seeing attending work hours increase in turn - and those of us who have "done our time" in residency might just say "screw it" and move on if our lives get too disrupted in turn.

I'm just dying to see where all these medical "dropouts" are going to go for gainful employment. Given your many posts on all the failures of the present medical practices, I would have thought that we are in desperate need of reform. It's clear you don't like this administration's attempt. Could you give us some idea of how the "free market" will solve this problem? And then, I'll ask you how the free market will deal with some of the other problems we have presently that health reform has tackeled. For instance, this morning I heard about the problems hemophiliacs face due to annual and lifetime dollar limitations imposed by health insurers.

I'm just dying to see where all these medical "dropouts" are going to go for gainful employment. Given your many posts on all the failures of the present medical practices, I would have thought that we are in desperate need of reform. It's clear you don't like this administration's attempt. Could you give us some idea of how the "free market" will solve this problem?

Your doctor will come from overseas, or not be a doctor - look for legions of "nurse managers" to provide your care.

Judging our educational system by the current crop of candidates and their ideas about governance, I would suppose that it won't be too long before we will be delighted to have a doctor who was educated in another country. But your suggested free market solution may ease our problems so long as we don't go all xenophobic and not allow anybody into our country. And I am willing to bet that you have taught some wonderful med students that have been educated in another country. I hope I have misread your intent - it's hard to believe that you would discount talent and brains just because they are educated in another country. Einstein and Neils Bohr weren't so bad, were they?

As you suggest, I've trained many excellent foreign doctors. I suspect there will be pressure to hire many of them with our upcoming doctor shortage. No doubt these doctors will put downward pressure on salary expectations for newer doctor-employees.

While I cannot predict what the future holds, it seems logical that without some sense of the potential for delayed gratification compared to other vocations, the overall caliber of physicians is likely to decline as a result, irrespective of their country of origin.

As to less compensation resulting in less competence... As cynical as I am, I find it hard to believe that all the smart, concerned, and ambitious people who are drawn to medicine will suddenly stop being so smart, concerned and ambitious. Who knows, they might want to help sick people.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.